Mental Health

The meaning of the term –mental health—is ambiguous; not only is it difficult to agree on its general application, but even in a single context it may be used in many different ways. This lack of agreement will probably continue because the term has been adopted for a variety of purposes. One conclusion, however, can be reached: –mental health—is not a precise term but an intuitively apprehended idea that is striving for scientific status while also serving as an ideological label.

Problems of definition

The word ‘mental’ usually implies something more than the purely cerebral functioning of a person; it also stands for his emotional-affective states, the relationships he establishes with others, and a quite general quality that might be called his equilibrium in his sociocultural context. Similarly, ‘health’ refers to more than physical health: it also connotes the individual’s intrapsychic balance, the fit of his psychic structure with the external environment, and his social functioning. It is not surprising that the combination of two such terms produces an elastic and ambiguous concept. Another ambiguity attends this phrase. In common usage ‘mental health’ often means both psycho-logical well-being and mental illness.

Definitions obviously vary with the perspective of the definers, the point of reference used, and the values considered important. Thus, the psychoanalytic perspective focuses on the intra-psychic life of the individual. Freud defined mental health in his programmatic statement: ‘Where id was, there shall ego be’ (1932, p. 112). Here the value is awareness of unconscious motivations and self-control based upon these insights. The interpersonal frame of reference, on the other hand, is more concerned with the functioning of individuals in interpersonal situations. Sullivan identifies a person’s drive toward mental health as those ‘processes which tend to improve his efficiency as a human being, his satisfactions, and his success in living‘ (1954, p. 106) and places major value on effective and efficient social functioning. The social relatedness perspective is exemplified by Fromm, who focuses on the individual’s relationship with the larger social environment.

The mentally healthy person is the productive and unalienated person; the person who relates himself to the world lovingly, and who uses his reason to grasp reality objectively; who experiences himself as a unique individual entity, and at the same time feels one with his fellow man; who is not subject to irrational authority, and accepts willingly the rational authority of conscience and reason; who is in the process of being born as long as he is alive, and considers the gift of life the most precious chance he has. ([1955] 1959, p. 275)

Here the values are humanism, individualism, freedom, and rationality.

The most comprehensive and definitive summary of the multiplicity of criteria used in defining mental health is that of Jahoda (1958). She rules out certain criteria as unsuitable because they are unsatisfactory for research purposes. ‘Absence of disease,’ for instance, is rejected as a criterion, not only because of the difficulty in circumscribing disease but also because common usage of the term ‘mental health’ now includes something more than the mere absence of a negative value. ‘Statistical normality’ is also considered unsuitable on the grounds that the term is unspecific, bare of content, and fails to come to grips with the question. Finally, ‘happiness’ and ‘well-being’ are ruled out because they involve external circumstances as well as individual functioning.

Jahoda then summarizes what are to her the acceptable sets of criteria in current use. These are attitudes toward the self, which include accessibility of the self to consciousness, correctness of the self concept, feelings about the self concept (self-acceptance), and a sense of identity; growth, development, and self-actualization, which include conceptions of self, motivational processes, and investment in living; integration, which refers to the balance of psychic forces in the individual, a unifying outlook on life, and resistance to stress; autonomy, which refers to the decision-making process, regulation from within, and independent action; undistorted perception of reality, including empathy or social sensitivity; environmental mastery, including the ability to love, adequacy in interpersonal relations, efficiency in meeting situation requirements, capacity for adaptation and adjustment, efficiency in problem solving, and adequacy in love, work, and play.

Since Jahoda’s statement is a summary and not an attempt to integrate the criteria currently used in defining or identifying mental health, various difficulties (many recognized and discussed by her) attend her presentation. The criteria are over-lapping, and the relationship between criteria is not spelled out (for example, the degree to which they are independent). Moreover, no method is indicated for identifying satisfactory indexes for the criteria, thus making it impossible to measure the degree of a particular criterion or even to discover its presence or absence. Ambiguities and different levels of specificity characterize the different criteria, and the impact of the social situation and the relevance of the society as context criterion are largely ignored.

Jahoda does not attempt a solution for these difficulties. She simply recognizes the impossibility of arriving at a ‘correct’ definition and of attaining a consensus, because values underlie the defi- nitions proposed and because the concept is used for different purposes. Jahoda’s analysis of mental health as a concept deals mainly with the problems it poses for the empirical researcher: whether—and if so, how far—the various criteria can be integrated into one criterion or a set of criteria; the kinds of criteria that are required by different definitions; whether and how one might distinguish between “optimal” and “maximal” mental health; and operationalizing the definitions used. She deals minimally with the approach that the student of society would take: the meaning of this concept in society, its various functions, the ways in which it constitutes and expresses societal values, and the nature of the kinds of social environments that influence a person’s psychological well-being. Nevertheless, her work represents the best summary of the current major definitions and the controversy connected with them.

Aspects of the mental health controversy

Discussions of the concept of mental health naturally reflect the interests of the principal groups involved in the mental health movement. One of the leading issues is whether “mental health” and “mental illness” should be conceptualized on the same continuum or on different continua that cut across each other. The conventional medical view holds that mental health is the absence of mental illness, that both terms represent the extreme ends of the same continuum, and that the difference between the two states is one of degree. A contrary view is that mental health is qualitatively different from mental illness and that a person can be both mentally healthy and mentally ill at the same time. Jahoda, as an advocate of the concept of “positive mental health,” maintains that the absence of certain qualities does not imply the presence of others. For example, the absence of hallucinations does not imply the presence of accurate self-appraisal; conversely, the presence of creativity does not exclude the presence of severe anxiety. But if mental health and mental illness are placed on different continua, then it becomes necessary to specify their relationship. For this reason, Conrad (1952) has suggested that “negative health,” or the absence of pathology, be used as an interstitial term.

A related issue is whether mental health is to be seen as a relatively constant and enduring function of personality or as a momentary function of person and situation. For instance, Klein (1960) distinguishes “soundness” from “well-being”: the former refers to the level of integration of the general, more enduring personality structure, and the latter to the individual’s current state of equilibrium. This distinction may be a useful way of identifying two different kinds of mental health.

There also are differences of opinion on whether the concept of mental health is ever value-free. Some authors—medically oriented professionals—view psychological health as analogous to physical health, which, they maintain, can be evaluated by objective medical standards, without regard to the patient’s sociocultural context. Another view maintaining that mental health is a value-free concept equates it with the statistically normal: mentally healthy behavior is that which is considered average or conventional behavior for a particular population. Here, good mental health is evaluated in terms of adjustment to and acceptance of current societal norms. Clearly, these criteria are not value-free. Indeed, many students of the field maintain that criteria of mental health cannot be established in complete independence from the particular values and ideology of the society or group in which they are formulated and applied. According to this view, the study of definitions of mental health becomes a branch of the sociology of knowledge. But such an approach, although sociologically meaningful, cannot settle the question of which criteria are the most useful for therapy and mental health research.

Some of those who maintain that all definitions of mental health are culture-bound hold that multiple criteria should be used, depending upon the values cherished by each society or subculture. Thus, criteria for mental health in the lower classes may have to be different from those for the middle classes, and those for citizens of Japan would have to differ from those for India or the United States. The issue here is that of the relation of the mental health of a person to the nature of the society in which he lives. Although this issue is rarely discussed, its clarification and resolution are critical in identifying the field of interrelated variables that are relevant to the study of mental health. What is needed is nothing less than a complete theory of the relation between the individual and society.

Other students of the field hold that the criteria for mental health, though value-laden, can transcend situational or cultural boundaries and that an area of general value consensus can be arrived at. For example, M. B. Smith has suggested that universal criteria for mental health might be “identified with the stability, resilience, and viability—in a word the system properties—of these external and internal subsystems of personality” (1959, pp. 680-681). Similarly, Fromm (1955) insists that criteria for mental health must be based on some concept of a universal human nature rather than on the values of particular cultures or societies.

In summary, mental health can be viewed either as an ideal-type concept or as an empirical construct referring to a state that actually occurs. In the former view, mental health is an ideal to be striven for but never fully attained; it serves, however, as a standard against which to measure any particular individual. In the latter view, mental health is realistically attainable, though there is much dispute about the frequency with which it is encountered.

Mental health as a movement and a profession

The emergence of the concept of mental health is closely related to the growth of the mental hygiene movement in the United States and to the development of psychotherapeutic practice and personality research. As an explanatory construct, “mental health” emerged out of the concern with “mental hygiene” that gained its first adherents at the beginning of the twentieth century. Originally, this social movement focused on improving the wretched conditions in mental hospitals and providing better care and treatment for the mentally ill wherever they might be. In the 1920s interest shifted to promoting “mental hygiene” and establishing child-guidance clinics. The term “mental health” began to replace “mental hygiene” in the 1930s, and by the late 1940s it assumed an independent status with a growing and enthusiastic social movement operating in its name. This shift in terms signified the beginning of the era of concern with the prevention of mental disorders rather than merely care and treatment and the broadening of focus to include all forms of social and psychological maladjustment rather than just the severely emotionally disturbed or psychotic. The movement began to promote “positive” mental health as a goal distinct from the elimination of mental illness.

The popularity of mental health as a desired value in the United States is in part related to its advocacy by those in the mental health movement and in part to the growth of psychoanalytic theory and acceptance of psychotherapeutic practice in the past several decades. The orthodox psychoanalytic viewpoint that mental health is a property of individuals and a function of intrapsychic development and dynamics is still dominant. It maintains that an individual acquires good mental health as a consequence of fortunate early socialization; psychoanalysis or some other form of psychotherapy is a corrective for unfortunate early development. Thus, the individual remains the unit of analysis, and psychological health is seen as a function of the individual’s unique, private intrapsychic development and life history. Subsequently, the unit of analysis was extended to include the patterning of an individual’s interpersonal relations. Recently, another view of mental health was put forward by the proponents of social psychiatry [see PSYCHIATRY, article on Social Psychiatry]. Only a few authors, such as Fromm (1955) and Frank (1948), take a comprehensive view of mental health as a function of the total society—its dominant ideologies, assumptions, norms, values, institutions, and general style of life. Such a perspective is largely ignored or considered irrelevant by the great majority of ideologists, practitioners, and researchers in the field of mental health.

Ideologists, practitioners, researchers

Action in the name of mental health has occasioned the development of three distinct groups whose membership may overlap but whose interests and functions are separable: they can be called the ideologists, the practitioners, and the researchers. The ideologists are primarily interested in promoting psychological well-being as a value and in encour-aging action to prevent and eliminate mental illness. Well-developed mental health organizations, both private and public, now exist in the United States at the national, state, and local levels. In 1960 the National Association for Mental Health reported that, in addition to the state mental health associations, there were some eight hundred affiliated local mental health associations in 42 states, with a total registered membership and volunteer participation exceeding one million persons (Ride-nour 1963). In addition, a network of federal governmental agencies, led by the National Institute of Mental Health (NIMH), spent a ast sum for research, training, education, demonstration, and the building and development of treatment facilities (during the fiscal year 1964/1965 the NIMH alone spent over $200 million). The NIMH also maintains links with the privately sponsored branches of the mental health movement. In addition to the federal government, each state and many cities and counties have a department of mental health or a mental health officer. Private and governmental agencies often join with practitioners to educate the public about mental illness and health, to urge persons to become concerned about their own and others’ psychological health, and to collect funds for research.

The importance of the mental health movement has enhanced the prestige and power of its practitioners, who range from psychoanalysts to marriage counselors. They have gradually widened their sphere of operation and now function in institutions such as schools, courts, and industry. Although many of their activities are undertaken in the name of mental health, little work is directed toward mental health as distinct from mental illness. Primarily, their concern is treatment; secondarily, it is research; it is only minimally prevention.

The interests of researchers in mental health span the entire range of human behavior from circumscribed biochemical problems to existential problems of living. Despite the increasing number of research projects over the past decade, etiological problems remain unsolved and the field awaits conceptual clarification.

Mental health and American values

The mental health concept is related to current and traditional American values in three ways. First, it reflects and embodies many of these values; second, it functions to preserve certain of them; finally, it is a highly valued end in itself. In fact, mental health has become so esteemed that in some circles it has taken on the characteristics of a secular religion. In the twentieth century, human health is prized as it has been in no other. In the United States, in particular, we have moved from valuing sheer physical health to cherishing the psychological well-being of the total person. In pursuing these goals, we have relied on medicine, psychology, and social science to produce more valid knowledge and techniques with which to serve this value. Science and medicine, in turn, are values that are used to promote psychological health as a social and ethical goal. Thus, the importance of health, the faith in science and medicine, the reliance on technology to produce means for the ends declared desirable by experts, and the development of professional skill and specialization as attributes of the technology all combine to maintain and reinforce mental health as a value.

The high degree of acceptance of this value also seems related to its congruence with the Protestant ethic. Kingsley Davis (1938) has suggested that the mental health movement took over the Protestant ethic as a system of conscious preachment and unconscious premises and that it bases itself upon much the same values. But we suggest that the movement has done more than take over the Protestant ethic—it has dressed it up in a modern scientific cloak. Thus it serves as a new ideology that recommends, in nonreligious, quasi-scientific terms, a way of dealing with personal troubles and anxieties without the necessity for becoming involved in broader social issues or societal reconstruction. In any case, its popularity among middle-class, college-educated Americans cannot be denied.

For some ideologists of the movement, “mental health” has become a mystique and a secular religion. Dicks, for example, proposes that it be conceived of as a new value in our world that is “comparable to the notions of ’finding God, ’salvation/ ’perfection’ or ’progress’ which have inspired various eras of our history, as master-values which at the same time implied a way of life. . . . Some of the attributes of a secular priesthood or therapeutae are attached to us, and it is questionable whether we ought to divest ourselves of them even if the community would let us” (1950, pp. 3-4). Thus, for the mental health enthusiast, “mental health” becomes the standard for evaluating human behavior. Further, the mental health idea implies a new conception of moral and social progress in the form of self-correctability, self-perfectibility, inner growth, personal fulfillment, and inward and outward harmony, or the like. We are told that in the same way that we have achieved physical comfort—through the instrumental application of knowledge and understanding—we can achieve psychological mastery over the self. This idea of progress embodies a new conception of success. No longer is it sufficient to measure achievement in tangible coin; we are persuaded to evaluate our-selves in terms of self-development and maturity. But there are no clear guidelines as to the means of reaching this goal or even to knowing that one has reached it.

Orientations toward mental health

Orientations toward mental health as a desirable objective, as a subject matter, and as a field of work, knowledge, and inquiry oscillate between two poles. On the one hand, mental health is seen as a restricted and circumscribed “state of being” and as the subject matter of a field of work that is a specialty among other specialties. The individual or his immediate social environment is the unit for analysis, attempted control, and change. On the other hand, mental health is seen as the sum total of the individual personality, and the field of work associated with it is a superordinate, all-inclusive science of man.

In the more restricted orientation, the acquisition of mental health is viewed as a technical problem that is to be solved under the direction and leadership of experts. Mental health technology is seen as being contained in and developed and transmitted by practitioners who claim special skills and expertise and who are legitimated by the society as the vehicle for the ethical application of knowledge about mental health. Operational techniques and procedures are established, and frames of reference and explanatory theories are developed and fiercely adhered to. In general this orientation stresses the separateness of persons and encourages them to seek inner tranquility and self-actualization on a private basis; psychological well-being is seen as a function of personality dynamics, which, in turn, are supposed to be primarily a function of early experience and only secondarily of later interpersonal relations. [For an approach that stresses primarily social factors, see PSYCHIATRY, article onSocial Psychiatry.]

By contrast, those who take an all-encompassing view of mental health phenomena claim as their province the entire range of human thought and behavior; they believe that the human panorama is to be interpreted within the mental health frame-work rather than vice versa.

These contrasting orientations have different advantages and disadvantages in achieving mental health objectives. The psychotherapeutic orientation is far more specific about the nature of the phenomena to be affected, be they biochemical, individual, or social; it therefore affords greater opportunity for intervention and control. However, by restricting the variables to be dealt with, it may neglect significant and, perhaps, crucial phenomena. By contrast, the broader orientation opens up greater possibilities of discovering the various inter-connections between the variables involved. however, its very diffuseness and scope make it a poor guide for scientific research or social action.

The functions of mental health ideology

The mental health ideology and movement function, in general, whether deliberately or inadvertently, to preserve and enhance certain values in American society. Outstanding among these is the human-istic value that emphasizes the importance of the individual as well as his development and fulfillment. Thus, the mental health movement contributes to and reinforces certain aspects of American democratic ideals and also promotes a form of “inwardness” by emphasizing introspection and self-awareness. By focusing on changing the individual rather than the society, the mental health movement directs effort away from social reconstruction and thereby functions to preserve the status quo and those middle-class values that are an intrinsic part of it. This is not to deny that some practitioners use the mental health idea as a vehicle for achieving social reform; but they are interested only in specific social changes which they hope to effect in the name of mental health, such as changes in child-rearing practices in the family or in the ways in which students are handled in public school.

For the ideologists, the conception provides a Weltanschauung of self-betterment to which they can devote themselves at a time when sociopolitical ideologies are unfashionable in the United States. Thus mental health is put forward as the panacea for all social problems and for the wholesale improvement of mankind. For the practitioner, on the other hand, the concept of mental health usually serves as a goal—albeit an ambiguous one—against which he can measure the current functioning of his patients and toward which he can direct his and their efforts; it is an implicit or explicit standard against which he measures the success and failure of his efforts and those of his colleagues.

Problems for the future

Despite the expansion of the mental health movement and the prestige of the professionals involved with it, little is known about how to achieve mental health. Moreover, the mechanisms for applying this meager knowledge and effecting the ends sought are extremely inadequate. Of the many issues that need resolution, three are central. The first is the necessity for conceptual extension beyond the individual intrapsychic life, interpersonal relations, and limited social contexts. For no matter how sophisticated, discerning, or scientific is our understanding of human beings as individuals, this framework is insufficient for understanding mental health, which also needs to be seen as a function of social roles, institutions, and communi-ties. The second problem concerns this very scope of the mental health conception, which, because it involves a number of aspects of human living, demands an integration of the biochemical, psychological, social, and philosophical disciplines that is not yet in sight. The third problem involves the difficulties in intervention, implementation, and control that would remain even if conceptual expansion and the integration of relevant disciplines were achieved. Even if mental health can be achieved by rational planning, how much planning of this kind is desirable? Would it not threaten other cherished values, or have consequences that we cannot now foresee? From one perspective, the problem of mental health is identical with the eternal question of how to lead the good life. Perhaps this is not subject matter for academic disciplines, whether they be expanded or integrated, but rather an emergent from the human condition, in its infinite complexity, only a part of which can be planned for. Perhaps we need to raise the issue of how much mental health can be achieved by science and planning. It may be that the ultimate goal of positive mental health for all will continue to elude us as one of our persistent human limitations.

Morris S. Schwartz and Charlotte Green Schwartz

[Directly related are the entries on Health; Illness; Life Cycle; Mental Disorders, Treatment of, article on THE Therapeutic Community; Psychiatry, article on Social Psychiatry; Psychoanalysis.Other material relevant to the concept of mental health may be found in Mental Disorders; and in the biographies of Freud; Rank; Reich; Sullivan.]

If personality is seen as referring to the relatively enduring needs, motives, attitudes, values, belief systems, and self-conceptions that characterize the behavior of the individual, there is good reason to expect a substantial relationship between social class (one’s position in the stratification structure) and personality.

The basis for expecting such a relationship rests on widely accepted assumptions regarding man and society. Human personality is to a large extent a product of the social learning experiences that the individual undergoes in the sociocultural environment in which he lives. Moreover, there seems to be almost complete agreement among social scientists that the early experiences of the individual are of critical importance in personality development and in later adjustment, although there is considerable disagreement as to the dynamics of the relationship between early experience and later personality. It is also generally accepted that personality continues to develop throughout the life cycle (although probably at a less rapid rate than in childhood) in response to learning experiences and environmental pressures which the person encounters in the performance of his social roles. Finally, it is readily apparent that one of the most pervasive aspects of the social structures impinging on the individual throughout his life cycle is the stratification system of his society.

This last observation is true not only because all societies have a system of stratification in which the members are differentiated into strata of unequal status but also because of the unique function of the family as a status ascription and socialization agency. Because in all societies the child is accorded the same status as his parents, the family of origin serves as the main link between the child and society. Since the family is the major agency charged with the early socialization of the child, its position in the stratification structure will to a large extent determine the social learning influences to which the child will be subjected during the most formative periods of his life. Moreover, the family’s position in the stratification structure will greatly affect the child’s choice of associates outside of the family, which in turn will go far in determining the social opportunities he will encounter throughout his life. Thus the stratification system may be seen as one of the most important and continuous social contexts in which the individual’s developmental history takes place; certainly, one’s position in it should have a substantial bearing on his personality. This is not to say, however, that personality is wholly determined by social class. The possible influences on personality development to which the individual is subjected are many and varied and are by no means all class-linked.

The two principal sources of research evidence on the relationship between social class and personality are studies of social class and the socialization of the child and studies of social class and mental illness. In the past 25 years many studies in both of these areas have appeared. Fortunately, reviews of much of this literature are available (Bronfenbrenner 1958; Dunham 1961; Sewell 1962; Mishler & Scotch 1963) so that only major trends and more recent developments are covered here.

Social class and socialization

In one of the early studies of social class and personality, Davis and Dollard (1940) attempted to show how the social structure influences the nature of the learning process by which Negro children are trained to take on the behavior appropriate to their position in the social stratification system of the southern United States. The authors trace the process by which the child learns and acquires from his parents, his family’s social clique, his peers, and his interactions with white adults the needs, motives, cognitions, attitudes, values, and behavior patterns of the class subculture of which he is a member. These results were based mainly on informal observational procedures and, consequently, are suggestive rather than definitive; but they stimulated many subsequent studies of social class and child rearing. Perhaps best known is the study by Davis and Havighurst (1946) of middle-class and lower-class Negro and white children in Chicago. Using interviewing procedures, they found that the social class differences were much greater than the race differences and clearly indicated that middle-class mothers were more restrictive than lower-class mothers in the critical early training of the child. For instance, middle-class mothers were more likely to bottle-feed, follow a strict nursing schedule, restrict the sucking period, wean earlier and more abruptly, and begin and complete toilet training earlier than lower-class mothers. They also followed stricter regimens in other areas and expected their children to assume responsibilities earlier.

These differences in early feeding and toilet training were widely interpreted by psychoanalytically oriented writers as evidence that middle-class child-training practices were baneful to middle-class children and were likely to produce mal-adjusted adults. Subsequent and more carefully designed studies of social class differences in child-rearing practices have failed to confirm the findings of the Chicago study. In fact, on many points, the results of later studies (see, for instance, Sears, Maccoby & Levin 1957) have contradicted those of the Chicago study—particularly on toilet-training and infant-feeding practices—and have shown that lower-class mothers are more restrictive and punitive in relation to basic needs than middle-class mothers. Urie Bronfenbrenner (1958), on the basis of a detailed examination of data from a number of studies covering a 25-year period, concluded that lower-class mothers have probably become more restrictive in infant feeding and toilet training since World War II, while middle-class mothers have become more permissive, with the result that the gap between them has tended to close. However, throughout this period, middle-class mothers have been consistently more permissive toward the child’s expressed needs and wishes, less likely to use physical punishment, and more accepting and equalitarian in dealing with the child than have lower-class mothers. Thus, it would appear that there is little evidence from these studies to support the view that the lower-class child undergoes socialization experiences that are more favorable to his later personality than does the middle-class child; if anything, the evidence points in the opposite direction.

Possibly as a result of these findings, and because empirical research has cast doubt on the importance of toilet training and infant-feeding practices for later personality (Sewell 1952), recent studies of social class and personality development have tended to place less emphasis on infant training and more stress on parent–child relationships extending into childhood and adolescence. Several studies illustrating this trend may be briefly mentioned. Kohn (1959 a; 1959 b) finds that middle-class parents emphasize internalized standards of conduct, including honesty and self-control, while working-class parents stress respectability, obedience, neatness, and cleanliness. Middle-class parents tend to respond to misbehavior in terms of the child’s intent and to take into account his motives and feelings, while lower-class parents focus on the child’s actions and respond in accordance with the seriousness of the act. Moreover, there is evidence that middle-class parents are less authoritarian in their relations with their adolescent children than lower-class parents but have higher expectations of them (Elder 1962). Rosen (1961) finds that not only do middle-class junior-high-school boys have higher achievement motives and values than lower-class boys, but that middle-class parents put more pressure on them to succeed, teach them to believe in success, and create conditions in which success is possible. Studies of lower-class adolescent boys, on the other hand, testify to the influence of peer groups and of the lower-class culture of the community, especially in socialization to delinquent roles (Miller 1958). Still other studies have shown that middle-class adolescents are trained to defer their gratifications and lower-class youths to satisfy their current needs (Schneider & Lysgaard 1953). Finally, many other studies show that middle-class parents, in comparison with lower-class parents, place more stress on values which result in high levels of aspiration and achievement in the educational and occupational spheres (Kahl 1953).

Another quite different recent emphasis in socialization research has been renewed interest in cognitive development. Studies thus far reported indicate that lower-class children suffer from cognitive deficits that may seriously impede their later adjustments to school and adult roles (Deutsch 1963; Hess & Shipman 1965).

Much more needs to be done to discover the full range of class differences in socialization practices and especially to determine their effects on personality development and adjustment in the various classes. Studies, not reviewed here, relating socioeconomic status to scores on personality tests indicate a low but positive correlation between social class and the personality adjustment of the child (Sewell 1962, pp. 348–349). Some good work on socialization and social class is being done, but much more is needed using better samples, a wider range of socialization practices, and better data-gathering and data-analysis techniques.

Social class and mental illness

The largest body of evidence on the relation of social class to personality comes from the findings of a number of studies of social aspects of mental illness. One of the most important of these is the study by Faris and Dunham (1939), who found, among other things, an inverse association between socioeconomic characteristics of Chicago census tracts and first admission rates for schizophrenia. Since the publication of this research, similar studies of American, European, and Asian cities have essentially replicated these results (Dunham 1961, pp. 274–290). Ecological studies of this kind have been criticized because of bias arising from socioeconomic selection in first admissions to mental hospitals; the possibility that mentally ill persons have drifted from the better into the poorer areas of the city after the onset of their illness; and reliance on purely ecological correlations. Studies (Clark 1948; Ødegaard 1956) based on the association between occupation or income and admission rates for psychoses, especially schizophrenia, generally confirm the results of the ecological studies, but are also subject to the criticism that admission rates to mental hospitals tend to be selective of lower-class persons.

Hollingshead and Redlich (1958), in their study of social class and mental illness in New Haven, improved on the earlier studies by obtaining detailed classifications of all cases in treatment with a psychiatrist or under the care of a psychiatric clinic or mental hospital, by carefully assessing individual socioeconomic status, by taking a city-wide control sample of normal persons for comparative purposes, and by computing rates for treated cases of various types of mental illness by class status. Most of their findings are for treated prevalence and therefore understate the total prevalence of mental illness in the community, but they clearly indicate that the lower classes have much higher rates for psychiatric illness, especially for psychoses.

Other evidence collected by Hollingshead and Redlich indicates that diagnosis and treatment favor the higher social classes, with the consequence that members of the lower social classes tend to be diagnosed more readily as psychotics, to receive less individually oriented treatment, and to remain in custodial care for much longer periods of time. Because this piling-up of cases might explain the higher treated prevalence rates of the lower classes, incidence rates (based on the number of patients who entered treatment during the interval of observation) were computed. Again the lowest social class had the highest rates, although the differences between the other classes were no longer as marked. Moreover, while there was no relationship between social class and the incidence of neuroses, the inverse relationship of class membership and psychoses remained, with the rate for the lowest class being twice that for the next highest class and almost three times as high as for the two highest classes. This finding is particularly impressive because it confirms the results of the earlier ecological and correlational studies.

But even the study just described is seriously defective because it is based only on treated cases. Evidence has been mounting for some time that the prevalence and incidence of mental illness in the community are much greater than the treated rates because many cases are either not treated or are handled by others than psychiatrists, mental health clinics, and mental hospitals. This is apparently true even for quite serious forms of mental illness. Recently, attempts have been made to obtain more satisfactory evidence concerning total prevalence of mental illness by means of sample surveys in which clinical examinations or symptoms inventories are used to determine mental health status. Obviously, the magnitude of the rate will depend on the inventories and the cutting points used in determining who is and who is not mentally ill. The results of the Midtown Manhattan Study (1962; 1963), based on a large probability sample of adults, are especially informative in that a consistent inverse relationship is found between socioeconomic status and poor mental health and a direct relationship between status and absence of significant symptoms of mental pathology. Of all of the many variables tested, socioeconomic status was the one most clearly associated with mental health. Moreover, this relationship held whether parental socioeconomic status or the person’s own socioeconomic status was taken as the status measure, and it persisted when age and sex were controlled.

The finding of an inverse relation between socioeconomic status of parents and impaired mental health is particularly significant because it indicates that successively lower parental status carries for the child progressively greater likelihood of inadequate personality adjustment in adulthood. The finding that one’s current socioeconomic status is even more closely related to one’s mental health suggests that the effects of low socioeconomic status are probably cumulative in that the vulnerable personalities developed by some low-status children prevent their upward mobility and destine them to the further burdens and stresses that low socioeconomic status adults typically encounter in the United States. Moreover, lower-class persons tend toward socially disturbing psychotic adaptations that further complicate their adjustment to an already stressful environment, while higher-status persons tend to respond to stress with mild neurotic responses that are socially more adaptive. Thus, the cumulative effects of unfavorable childhood and adult experiences on the lower-class person may result in a higher degree of vulnerability not only to mental illness but also to the development of more serious psychiatric symptoms.

Another important finding of the Midtown Manhattan Study is that those who are downwardly mobile present more symptoms of mental disturbance than those who are nonmobile, with those who are upwardly mobile having the fewest symptoms of all. Evidence indicates that downward mobility is associated with the character disorders, or personality-trait disturbances, while upward mobility tends to be associated with neurotic behavior. These findings confirm the conclusions of earlier studies based on clinical observations (Hollings-head & Redlich 1958). The task of unraveling cause and effect in this area is indeed challenging and demands further research; whereas mobility may result in some types of psychiatric illnesses, it is also likely that certain personality characteristics—including psychiatric symptoms—may help determine who rises or falls in the stratification system (Dunham et al. 1966).

The one finding from the studies of social class and mental illness which comes through most clearly is that the lowest social class has the highest incidence and prevalence of major psychiatric illness. The explanations offered for this finding vary considerably, but they may be conveniently subsumed under three general notions. First is the claim that class variations in rates of mental illness are due to the way in which a social system functions over time to sort and sift persons with certain personality characteristics or vulnerabilities into social class positions. Second, it is argued that differences in the extent and nature of environmental stress in the various classes account for differences in rates. Finally, some authors argue that class differences in socialization, especially early socialization, are responsible for differing rates of mental illness among the various social classes. As we have seen in our examination of the research evidence so far available, it is clear that no one of these explanations has ever been subjected to anything approaching a scientifically adequate test.

It may be concluded that there are good theoretical reasons for expecting an association between social class and personality development and adjustment. However, studies to date do not indicate a sizable relationship but suggest that lower-class status is associated with socialization experiences that foster the development of needs, motives, attitudes, belief systems, self-conceptions, cognitive modes, and styles of coping with stress which result in personality maladjustment. Much more needs to be known about the socialization experiences that members of the various classes undergo, particularly how these affect personality systems. Finally, more systematic and theoretically informed studies of the role of social class in the etiology of mental illness are greatly needed.

Bronfenbrenner, Urie 1958 Socialization and Social Class Through Time and Space. Pages 400–425 in Society for the Psychological Study of Social Issues, Readings in Social Psychology. 3d ed. New York: Holt.

Clark, Robert E. 1948 The Relationship of Schizophrenia to Occupational Income and Occupational Prestige. American Sociological Review 13:325–330.

Davis, Allison; and Bollard, John (1940) 1953 Children of Bondage: The Personality Development of Negro Youth in the Urban South. Prepared for the American Youth Commission. Washington: American Council on Education.

Davis, Allison; and Havighurst, Robert J. 1946 Social Class and Color Differences in Child Rearing. American Sociological Review 11:698–710.

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Mental Health

Encyclopedia of Public Health
COPYRIGHT 2002 The Gale Group Inc.

MENTAL HEALTH

The field of mental health has made many advances, particularly since 1980. These developments include an increased understanding of the brain's function through the study of neuroscience, the development of effective new medications and therapies, and the standardization of diagnostic codes for mental illnesses. However, many questions about mental health remain unanswered, and many people around the world are unable to benefit from the knowledge and treatments that are available.

Seven in ten Americans with a mental illness do not receive treatment. Biases against mental illness and lack of public awareness are among the obstacles that limit access to treatment and affect willingness to seek care. Fewer individuals with major psychiatric illnesses were institutionalized in the United States in the year 2000 than in 1980, but limited community resources had not yet met existing treatment needs. Over one-third of the homeless in the United States have a severe mental illness. The prevalence of dementia is rising as people are living longer, adding to the need for more resources. One of the main challenges for the field of mental health is overcoming the gap between an increasingly sophisticated understanding and treatment of mental illness and the availability of these advances to individuals and populations in need.

Mental, or psychiatric, illnesses are a major public health concern. They adversely affect functioning, economic productivity, the capacity for healthy relationships and families, physical health, and the overall quality of life. They cut across racial, ethnic, and socioeconomic lines to affect a significant proportion of communities worldwide. They tend to develop and manifest in the early adult years, often preventing individuals from leading full and productive lives. The National Comorbidity Survey of 1994 found nearly half of the individuals in its random U.S. sample had a psychiatric disorder over their lifetime, and almost 30 percent had one in the past year. The World Health Organization's World Health Report 1998 lists mood and anxiety disorders among the leading causes of morbidity and mood disorders as the leading cause of severely limited activity. Mental disorders account for a quarter of the world's disability. Comorbidity (having more than one illness) is common and even further increases the risk of disability. Suicide is the eighth leading cause of death in the United States and the third leading cause in the fifteen- to twenty-four-year-old age group. More people die by suicide than homicide.

Dianne Hales and Robert Hales define mental health as

the capacity to think rationally and logically, and to cope with the transitions, stresses, traumas, and losses that occur in all lives, in ways that allow emotional stability and growth. In general, mentally healthy individuals value themselves, perceive reality as it is, accept its limitations and possibilities, respond to its challenges, carry out their responsibilities, establish and maintain close relationships, deal reasonably with others, pursue work that suits their talent and training, and feel a sense of fulfillment that makes the efforts of daily living worthwhile (p. 34).

A healthy pregnancy, adequate parenting, secure attachments to caretakers, regular involvement in groups, and stable intimate relationships all contribute to the development and maintenance of mental health. Mental health does not imply the absence of distress and suffering, or strict societal conformity. Mental health and illness, idiosyncratic beliefs and delusions, sadness and depression, and worry and severe anxiety lie on a continuum. An essential criterion for defining behavioral patterns or symptoms of psychological distress as a mental disorder is that they become significant enough to be functionally disabling and impose substantial increased risks ranging from an important loss of freedom to suffering pain, disability, or death.

Both genetic inheritance and environmental factors influence one's vulnerability to mental illness. Twin and family studies and genetic research have demonstrated the former, though specific genes have been difficult to identify, and there may be multiple genes involved in most psychiatric disorders. Traumatic events throughout one's lifetime, including childhood abuse or neglect, major losses, violence, military combat, and dislocation (as among the urban homeless or wartime refugees) are known to threaten mental stability. Nontraumatic stressors, including unemployment, bereavement, and relational or occupational problems, can impact mental health. Nutritional deficiencies (such as vitamin B12), infections (such as syphilis and HIV [human immunodeficiency virus]), and heavy metal poisoning (such as lead) can all cause psychiatric syndromes. Substance abuse contributes significantly to the exacerbation or even precipitation of other psychiatric illnesses and complicates their treatment. Poverty and home-lessness are risk factors for many of these problems, but may also be the outcome of psychiatric illness and the inability to function independently.

Many models of mental health and illness have been proposed. Emil Kraepelin (1856–1926) contributed to the development of the precise categorization of mental illnesses, particularly in distinguishing the long-term course of psychotic and mood disorders. Sigmund Freud (1856–1939) developed the theory of psychoanalysis, through which he claimed that symptoms of psychiatric disorders, as well as many phenomena of everyday life, have unconscious meanings and sources. Erik Erikson (1902–1994) formulated a theory of human development with specific tasks and crises at different stages of the life cycle. Failure to master these stages can lead to various forms of psychopathology. Neuroscientists have demonstrated molecular models of illness, which involve genetic, developmental, functional, anatomical, and molecular abnormalities of the brain. The biopsychosocial model, proposed by George Engel in the 1970s, integrates the biological, genetic, and molecular mechanisms of illness with a psychological understanding of personality development and response to stress as well as social, cultural, and environmental influences.

The Diagnostic and Statistical Manual of Mental Disorders (its 4th edition, DSM-IV, was published in 1994) is the product of research on standardized diagnostic criteria aimed at creating a common, validated descriptive system for all mental health care providers. It is nearly universally accepted, as it classifies and describes categories of illness and aims to be neutral about controversial theories of etiology (see Table 1). The following descriptions of various mental disorders are based on DSM-IV criteria.

Affective disorders involve a cyclical pattern of significant mood disturbance. A major depressive episode may be precipitated by a stressful life situation but also has genetic factors. Disturbances in appetite, sleep, energy, concentration, and sexual interest are common symptoms. The majority of patients respond to treatment with antidepressant medication and/or psychotherapy. An individual who has long-term (over two years) of minor to moderate depressive symptoms may have

source: Kessler, R.C. et al. (1994). "Lifetime and Twelve–Month Prevalence of DSM–III–R Psychiatric Disorders in the United States: Results from the National Comorbidity Study." Archives of General Psychiatry 51:8–19.

Affective disorders

Major depressive episode

12.7

21.3

17.1

7.7

12.9

10.3

Manic episode

1.6

1.7

1.6

1.4

1.3

1.3

Dysthymia

4.8

8.0

6.4

2.1

3.0

2.5

Any affective disorder

14.7

23.9

19.3

8.5

14.1

11.3

Anxiety disorders

Panic disorder

2.0

5.0

3.5

1.3

3.2

2.3

Agoraphobia without panic disorder

3.5

7.0

5.3

1.7

3.8

2.8

Social phobia

11.1

15.5

13.3

6.6

9.1

7.9

Simple phobia

6.7

15.7

11.3

4.4

13.2

8.8

Generalized anxiety disorder

3.6

6.6

5.1

2.0

4.3

3.1

Any anxiety disorder

19.2

30.5

24.9

11.8

22.6

17.2

Substance use disorders

Alcohol abuse without dependence

12.5

6.4

9.4

3.4

1.6

2.5

Alcohol dependence

20.1

8.2

14.1

10.7

3.7

7.2

Drug abuse without dependence

5.4

3.5

4.4

1.3

0.3

0.8

Drug dependence

9.2

5.9

7.5

3.8

1.9

2.8

Any substance abuse/dependence

35.4

17.9

26.6

16.1

6.6

11.3

Other disorders

Antisocial personality

5.8

1.2

3.5

—

—

—

Nonaffective psychosis*

0.6

0.8

0.7

0.5

0.6

0.5

Any of the disorders above

48.7

47.3

48.0

27.7

31.2

29.5

dysthymia. Substance abuse, medical disorders (such as hypothyroidism), and normal life cycle events in which hormonal changes are prominent (such as the postpartum period) can all cause symptoms of depression and should be considered carefully during an assessment. An adjustment disorder is a milder disturbance of mood that may occur in response to a stressful life situation, such as a personal loss or financial crisis, and that usually resolves when the stress is relieved. About 1 percent of the general population has bipolar disorder, also called manic-depressive disorder, in which manic episodes are present as well as depressive episodes. Mania is characterized by a persistently elevated or irritable mood for at least a week, often with decreased need for sleep, rapid speech, impulsivity in spending and other behaviors, and grandiosity. In more severe manic and depressive episodes, psychotic symptoms may emerge, which can complicate treatment. Bipolar disorder is treated with mood stabilizers, such as lithium or valproic acid, and supportive management. Antidepressant medications alone can precipitate mania in susceptible patients.

Psychotic disorders are characterized by "positive" symptoms such as hallucinations, delusions, and bizarre behaviors, as well as "negative" symptoms such as paucity of speech, poverty of ideas, blunting of affective expression, and functional deterioration. Cognitive problems such as disorganization of thought processes also occur. Schizophrenia is a chronic, disabling illness that affects almost 1 percent of the world population, independent of ethnic or cultural background. Risk factors include a family history and possibly psychosocial stressors. The precise cause is still unknown, but it is clear that certain areas of the brain and certain neurotransmitters are involved. Many of those affected are unable to maintain work or relationships and require supportive services to help them manage basic needs such as shelter and food. Treatment includes antipsychotic medication, comprehensive social services including social and occupational rehabilitation if possible, and substance abuse treatment if necessary. Newer antipsychotic medications such as clozapine, olanzapine, and risperidone have been able to treat more symptoms generally with fewer side effects, allowing many to lead more productive lives. Some patients with schizophrenic-type illness also experience prominent affective symptoms nonconcurrently and may have schizoaffective disorder. These patients often require a mood stabilizer as well as antipsychotic medication. Substance use, especially hallucinogens and stimulants (such as amphetamines and cocaine), can precipitate psychotic symptoms, and these may even endure beyond the period of substance use. Some medical conditions (such as epilepsy and delirium) and some medications (such as steroids) can also cause psychotic symptoms and should be considered in the assessment and treatment of psychosis.

Anxiety disorders are among the most prevalent psychiatric disorders in the general population, and these disorders lead to both psychological distress and increased health care utilization. Panic disorder often manifests with somatic symptoms, such as palpitations, chest pain, nausea, trembling, dizziness, and shortness of breath, and can be easily confused with a medical disorder by both patients and doctors. Patients develop persistent concerns about having further panic attacks. Some develop agoraphobia, or a fear of being in public places where their attacks may be triggered. Other phobias include simple phobia, such as fear of heights or specific animals, and social phobia, which is a marked and persistent fear of certain or all social situations, such as speaking in public or being around others in general. People with obsessive-compulsive disorder have obsessions, characterized by recurrent or persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate, and/or compulsions, characterized by repetitive behaviors or mental acts often performed in response to an obsession. After one experiences a traumatic event, in which actual or threatened death or severe injury is witnessed or experienced, one may develop post-traumatic stress disorder. Intrusive recollections of the event (such as nightmares), avoidance of reminders of the event, and increased arousal (such as increased vigilance for potential threats) can all cause significant distress and impairment following a wide range of traumatic events, including an accident, military combat, torture, or rape. Generalized anxiety disorder is characterized by excessive and persistent anxiety or worry about a number of events or activities, such as work or school performance. For all anxiety disorders, specific psychopharmacologic and psychotherapeutic (such as cognitive-behavioral therapy) techniques of treatment can be effective and complementary.

Substance-use disorders are quite common and occur in all segments of society. They can lead to accidents, violent crime, and major problems in school and at work. They can cause or complicate various medical and psychiatric illnesses. Liver failure, ulcers, heart attacks, cognitive disorders, and depression are among the potential outcomes of various substances. These disorders pose major public health concerns for public safety, health costs, economic productivity, and pregnancy risks, among others. Substance abuse is defined as a maladaptive pattern of use indicated by continued use despite persistent or recurrent social, occupational, psychological, or physical problems caused or exacerbated by the use of the substance; or recurrent use in situations that could be physically hazardous (such as driving while intoxicated). With substance dependence, signs of physical dependence such as withdrawal symptoms are often present, and the person spends a great deal of time involved in substance-related activities, uses more of the substance than intended, is unable to cut down, and continues to use the substance despite social, occupational, or physical problems related to it. The first steps of treatment involve developing insight, acknowledging the problem, and wanting to change. There are various self-help groups (such as Alcoholics Anonymous), comprehensive treatment programs, psychosocial interventions, and medications that can help lead to successful recovery for the majority of those with substanceuse disorders.

Childhood disorders include pervasive developmental disorders, such as autism, which occurs in four out of ten thousand people; mental retardation, which can be caused by a variety of genetic abnormalities or prenatal insults; and attention deficit–hyperactivity disorder, which can lead to significant problems in school and in social relationships. Childhood abuse and neglect are tragically quite common, with one million children affected annually in the United States alone. These can have major adverse effects on development of personality, relationships, and the ability to function in the world.

Personality disorders are usually first evident in late adolescence and are characterized by pervasive, persistent maladaptive patterns of behavior that are deeply ingrained and are not attributable to other psychiatric disorders. Biological and genetic factors, as well as developmental difficulties, are significant contributors. Other disorders described in DSM-IV include eating disorders, with restriction (anorexia) and/or binging and purging (bulimia) and impulse control disorders (e.g., kleptomania). Somatoform disorders cause physical symptoms with no apparent medical cause (e.g., hysterical paralysis).

Gender, race, ethnicity, and culture are important factors in determining the expression and risk of mental disorders, and these factors also impact on treatment considerations. Certain disorders are more prevalent in women, such as depression and eating disorders, and some in men, such as substance abuse. Cultural background may influence the idioms of psychological distress. For example, nervios describes for many Latinos a constellation of somatic, anxiety, and depressive symptoms distinct from particular DSM-IV diagnoses. Psychiatric disorders are the main risk factor for suicide, but rates vary significantly depending on gender, age, race, religion, marital status, and culture.

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Mental Health

Mental Health

Mental health has attracted considerable attention from social scientists. Poor mental health frequently creates personal distress for the individual and those around that individual; often has social causes; has significant social costs in the form of dependency, incapacity, and unemployment; and may also lead, on occasion, to social disturbance and disruption. Consequently social scientists have contributed to a series of related debates about the validity and boundaries of the concepts of mental health and illness, the social distribution and causes of mental illness, and the appropriate care and treatment of mental illness. To a more limited extent, social scientists have also added to discussions about the ways to facilitate and enhance mental health.

When defined positively, mental health tends to be described rather loosely as a state of psychological well-being or satisfactory psychological functioning. More frequently, however, much as with health generally, it is simply defined negatively as the absence of mental illness. Based on an analogy with physical illness, mental illness refers to mental functioning that is considered disordered and described in lay terms as mad, disturbed, or disruptive or as anxiety and unhappiness that is more extensive than usual. While the indicators of mental illness often take the form of behavior that seems inexplicable or unintelligible, the judgment made is of some pathology of mental functioning. In Madness and Civilization the social theorist Michel Foucault (1926–1984) argued that unreason is the defining characteristic of madness, although whether this applies to the full range of mental disorders that are now identified, which extends well beyond the narrower category of madness, is contested. In severe cases, mental illness impairs the individual’s capacity to carry out some ordinary tasks of living, although symptoms are often episodic. Mental illness can also generate behavior dangerous to self or others, which may be used to justify legal powers of detention on the grounds of the person’s lack of reason and the perceived threat to his or her own safety or that of the public. In less severe cases, it can lead to distress and suffering and difficulties with certain aspects of daily living. Consequently satisfactory performance of normal tasks of living often becomes a key indicator of mental health.

The use of the language of health and illness reflects the role doctors have played in offering care and treatment for psychological problems. In European and North American societies medical understandings, which draw on a range of scientific ideas, tend to be dominant and inform much lay discourse, especially about mental illness. However, in many contexts the term mental disorder, which has fewer medical connotations, is used. The impact of scientific ideas, as well as the ideas themselves, has varied historically and cross-culturally, and there have been times and places when the understandings have been magical or religious rather than scientific. Magical or religious ideas relating to mental illness have not entirely disappeared from lay understandings, such as when people think a mental or physical illness is a judgment of God or that health is a matter of luck and good fortune.

Modern-day medical ideas about mental illness have largely been developed in psychiatry, a medical specialty that emerged as a profession in the mid-nineteenth century from the associations of doctors working in charitable and public asylums that catered for “lunatics” and had powers of detention. In Europe a few institutions for lunatics were set up in the medieval period; these were followed first by small private madhouses in the sixteenth and seventeenth centuries and then, from the beginning of the nineteenth century, by charitable and public asylums. As the century progressed asylums became increasingly large-scale. They were mainly staffed by untrained attendants, with doctors usually the key figure of authority.

In the twentieth century asylum attendants were transformed into mental health nurses, and a range of other professionals (e.g., mental health social workers, psychotherapists, and clinical and health psychologists) started to contribute to the care and treatment of those with mental health problems and to understandings about mental health and illness. Mental health practice outside the asylum also expanded in the twentieth century. In the mid-twentieth century there was a move toward “community care,” which is the provision of services within community settings, even for those with more severe disorders, with far fewer mentally ill admitted to a psychiatric bed (where compulsory powers of detention are frequently used). The extent and quality of community services have often been questioned.

The types of mental illness identified by psychiatrists are diverse, ranging from the relatively severe and less common, such as schizophrenia, to the less severe and far more common, such as mild forms of depression and anxiety. Classifications have varied enormously over time, and during the second half of the twentieth century there were major attempts to systematize and standardize mental illnesses in order to improve the reliability of psychiatric diagnosis. In the twenty-first century two major classifications were developed: the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and the listing of mental disorders in The International Classification of Diseases. The two classifications do not group mental disorders in the same way.

An earlier distinction widely used in the early postwar decades was between psychoses and neuroses, a contrast between more and less severe disorders that linked to symptom differences and ideas about causation. Psychoses were held to be primarily disorders of thought (i.e., Foucault’s unreason) and caused by biological factors. Psychoses were typified by the delusions and hallucinations of schizophrenia, the archetypical madness, associated with disturbed and sometimes difficult behavior. Bipolar disorder (formerly referred to as manic depression) is also placed in this category, as are usually disorders where there is clear brain pathology, such as the senile dementias. Neuroses, such as anxiety states and phobias, were considered primarily disorders of emotion (usually called “affect” or “mood” by psychiatrists) rather than thought and were held to have psychological causes. However, in its third edition in 1980, the DSM decided (not entirely successfully) to eschew etiology as a basis for classification shifting to a symptomatological categorization and excluding the term neurosis. Official classifications also include a range of conduct or personality disorders in which the main symptoms relate to behavior, such as “antisocial personality disorder,” anorexia nervosa, and substance use disorders, including alcoholism and drug addiction. Comparison of the different editions of the DSM is salutary. According to Allan V. Horwitz, the number of mental disorders listed in the 1918 edition of the DSM was 22, whereas by the fourth edition in 1995 it was nearly 400. Such increases necessarily broaden the boundaries of mental disorder and narrow those of mental health.

Consistent with medicine’s interest in the body, psychiatry has developed a “biomedical” model of mental illness. The biomedical model focuses on physical causes and the provision of physical treatments, although psychiatrists often deploy a wider range of understandings in their practice. The search for physical causes has concentrated on inheritance, brain pathology, and biochemistry. While there is strong evidence of a genetic tendency for more severe mental disorders, there can be no doubt that environmental factors play a part in causation, even with severe disorders, and are important to mental health. For instance, the evidence from a range of studies has shown that genetic factors play a role in the etiology of schizophrenia, but there is also evidence of environmental factors having a role. Biochemical processes in the brain have been shown to underpin some mental illnesses, most obviously conditions such as Alzheimer’s disease. However, significantly data also indicate that social and behavioral factors, such as exercise (physical and mental) as well as diet and obesity, play a part in the complex etiology of Alzheimer’s disease.

Biochemical changes in the brain are associated with other mental disorders. There is evidence, for instance, that serotonin levels play a role in depression. But in contrast to Alzheimer’s, it is not clear that brain pathology is the cause of depression. The build up of serotonin may be a consequence of social and psychological experiences that are themselves better viewed as the cause of the depression. Such examples indicate that the causes of any mental illness are multifactorial and are not the same for one disorder as for another. They also indicate that debates about causation that have so vexed discussions of mental illness depend in part on the choice of which causes to examine. Psychiatrists have tended to focus on physical causes and to give them primacy, downplaying social and psychological factors.

Evidence of the importance of social and psychological factors to mental health comes from a range of studies. Many studies show that early childhood experiences affect mental health and that external stresses (stressful life events or ongoing difficulties, whether in childhood or later) can lead to mental disorder, although some would argue that in some disorders stress is more a precipitating factor than a cause. Data on the distribution of mental disorders across populations also display a marked social patterning. International studies show that a condition similar to schizophrenia is common across a wide range of societies. However, within any given society data indicate that schizophrenia is more common among groups with lower socioeconomic status and that this difference cannot be adequately accounted for by individuals with schizophrenia drifting down the socioeconomic scale. The link between socioeconomic status and mental illness applies to other disorders, such as depression. It has been argued that depression is due not only to the frequency of adverse life events but also to difficult circumstances and low levels of social support, which affect coping and its adverse vulnerability. There is also a marked patterning by gender. Whereas levels of schizophrenia are roughly the same for men and women, depression and anxiety are far more common in women than men, and personality and conduct disorders are more common in men. Part of this difference appears to be due to gender socialization and differing expectations as to appropriate emotions and behavior. There are also ethnic differences in the patterning of mental disorder. In the United Kingdom, for instance, a 1997 study by James Nazroo showed that schizophrenia is more commonly diagnosed in Afro-Caribbean men than in other social groups, though the reasons for this are not entirely clear.

Equally controversial have been related issues around the validity and boundaries of mental illness. A number of authors from different theoretical perspectives have argued that it is only reasonable to talk of illness when there is a clear physical pathology. For the psychiatrist Thomas Szasz, who famously argued in 1961 that mental illness was a myth, this meant recognizing that disorders such as senile dementia are diseases of the brain. Where there is no biological pathology, Szasz stated, psychological problems should be termed “problems in living” and not regarded as illnesses at all. From a rather different perspective, a range of sociologists has argued that mental illness, with its overtly behavioral symptoms, is best understood as a form of deviance (i.e., a behavior that breaks social norms) and not as illness. This position was developed by the psychotherapist T. J. Scheff in his well-known 1966 study Being Mentally Ill. These two positions reflect a long-standing contest between those who espouse the biomedical model of mental disorder and wish to appropriate psychological problems to the domain of physical illness—a process sociologists term medicalization and which is reflected in the expansion of psychiatric categories—and those who wish to appropriate mental disorder to the social (or psychological) domain of behavior considered unacceptable or difficult. Horwitz, in Creating Mental Illness, accepts that the boundaries of mental health and illness are set by society and tries to resolve the conflict between the two positions by stating that a condition is a valid mental illness or disorder if (a) it involves a psychological dysfunction that is defined as socially inappropriate, and (b) it is socially useful to define the dysfunction as a disease.

Given such disputes, not surprisingly a further major area of controversy concerns care and treatment. When charitable and public asylums were first established, the most influential therapeutic model was that of “moral treatment.” This was a set of ideas about the importance for “lunatics” to live in a supportive, well-ordered, and wellstaffed environment that built on the individual’s capacity for self-control to facilitate his or her return to health. However, this social model, which was an important component of the pro-institutional discourse that underpinned the establishment of asylums, was resource intensive and difficult to implement in practice, especially when asylums became large-scale. The challenges of asylums were among the reasons they were increasingly replaced by biomedical approaches. Treatments in the early twentieth century included drugs, such as morphine and chloral hydrate, and various forms of hydro and electrical therapy. In the late 1930s electro-convulsive therapy (ECT) and psychosurgery (which involves the cutting of certain brain tissues) were introduced, and from the mid-1950s a range of synthesized drugs began to be used starting with chlorpromazine, an antipsychotic. In the beginning of the twenty-first century psychotropic medications provide the dominant form of treatment for mental health problems, from the most to the least severe, although many professionals accept that the drugs control symptoms rather than provide cures. Some medications, notably the antipsychotics, have unpleasant side effects, and patients may be reluctant to take them except by compulsion; they are also often prescribed on a long-term basis, which increases the risks to patients. Yet a number of factors encourage the medical reliance on drugs: efficacy in controlling symptoms; the scope of doctors’ expertise with its concentration on the physical at the expense of the psychological and social; pressures of time that make more intensive therapies seem harder to provide; and heavy marketing by the pharmaceutical industry.

Psychological theories and therapies have, however, played an important role in ideas about mental health and the treatment of the less severe forms of mental illness. In the first half of the twentieth century psychoanalysis had a major impact, and “talking cures” began to be used by trained psychoanalysts, especially for private patients (in the United States psychoanalysis had widespread acceptance within psychiatry). Psychological theories also informed child and educational psychology and the “mental hygiene” movement that flourished in the United States in the early decades of the twentieth century, in which the focus was on improving and sustaining mental health through education, early treatment, and public health.

However, some psychologists, highly critical of psychoanalysis, developed their own therapies based on the behaviorist ideas that swept academic psychology from the early decades of the twentieth century. Early behavior therapy excluded attention to thought and meaning but was gradually replaced by cognitive behavior therapy (CBT), which concentrates on the individual’s ways of thinking and is seen by some as offering a relatively speedy and effective route to mental health, especially for less severe disorders. CBT has been influenced by “positive psychology,” which is a set of ideas that seeks to encourage individuals to focus on what can give meaning in life, especially their strengths. Some also argue that CBT can be of value in treating psychosis. Yet psychological therapies such as physical remedies mainly concentrate on dealing with mental health problems that have already developed and not on mental health maintenance and prevention, the area to which social scientists have arguably more to contribute.

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Mental Health

Gale Encyclopedia of Psychology
COPYRIGHT 2001 The Gale Group Inc.

Mental health

Personal well-being, characterized by self-acceptance and feelings of emotional security.

After decades of concentrating on mental illness and emotional disorders, many psychologists during the 1950s turned their focus toward the promotion of mental health. Attempts to prevent mental illness joined the emphasis on treatment methods, and promotion of "self-help" in many cases replaced the dependence on professionals and drug therapies. American psychologist Gordon Allport (1897-1967) viewed the difference between an emotionally healthy person and a neurotic one as the difference in outlook between the past and the future. Healthy people motivate themselves toward the future; unhealthy ones dwell on events in the past that have caused their current condition. Allport also considered these qualities characteristic of mentally healthy individuals: capacity for self-extension; capacity for warm human interactions; demonstrated emotional security and self-acceptance; realistic perceptions of one's own talents and abilities; sense of humor, and a unifying philosophy of life such as religion.

In the United States, the Community Mental Health Centers Act of 1963 attempted to localize and individualize the promotion of personal well-being. Community mental health centers were established for outpatient treatment, emergency service, and short-term hospitalizations. Professional therapists and paraprofessionals consulted with schools, courts, and other local agencies to devise and maintain prevention programs, particularly for young people. Halfway houses enabled formerly ill patients to make an easier transition back to everyday life. Youth centers provided an available source of counseling for jobs and personal problems. Hot lines became staffed 24 hours a day in attempts to prevent suicide and child abuse .

Aided in large part by these community mental health centers, mental health professionals have strived to reduce the severity of existing disorders through the use of traditional therapies, the duration of disorders that do occur, and the incidence of new mental illness cases. In addition, attempts have been to decrease the stigma attached to mental illness by making mental health services more commonly available. Self-help strategies have also played an important role in the mental health arena. People with particular anxieties are encouraged to reduce them through training. For example, people afraid to speak in public are encouraged to take classes to help them cope with their anxiety and overcome it so that it does not interfere with their personal or professional lives. The proliferation of self-help support groups are also outgrowths of the efforts to personalize, rather than institutionalize, mental health care. People who participate in such groups not only learn to cope with the stresses that erode their wellbeing, they also receive the social support thought to be equally important in building strong mental health.

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